Healthcare Provider Details

I. General information

NPI: 1538478045
Provider Name (Legal Business Name): DANA LYN MEDLOCK CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 COLLINS AVE
RICHMOND HEIGHTS MO
63117-2115
US

IV. Provider business mailing address

1504 COLLINS AVE
RICHMOND HEIGHTS MO
63117-2115
US

V. Phone/Fax

Practice location:
  • Phone: 314-288-5249
  • Fax:
Mailing address:
  • Phone: 314-288-5249
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: